Clinician Update
Transcription
Clinician Update
Clinician Update Atrial Fibrillation Outpatient Presentation and Management Michael D. Ezekowitz, MBChB, DPhil, FRCP; Timothy H. Aikens, BA; Rangadham Nagarakanti, MD; Timothy Shapiro, MD C Downloaded from http://circ.ahajournals.org/ by guest on September 29, 2016 for an associated condition. The patient has a normal blood pressure (125/80 mm Hg) and a well-controlled irregular heart rate (72 bpm) on atenolol 50 mg daily. There are no interval ECG changes apart from the atrial fibrillation suggestive of an acute process. On examination, he has a short 1/6 systolic murmur at the apex without radiation. He has no evidence of heart failure. Neurological examination is normal. Medications include atenolol 50 mg daily, lisinopril 5 mg daily, metformin, atorvastatin 20 mg daily, aspirin 325 mg daily, and clopidogrel 75 mg daily. Immediate hospitalization is not needed. ase Presentation—A 68-year-old white man presents to the cardiology office complaining of mild fatigue. A new and first finding is an irregular pulse. Atrial fibrillation is confirmed on 12-lead ECG. He has no additional symptoms. Four months earlier, he had a drugeluting stent placed for a discrete proximal left anterior descending artery lesion. Past history includes hypertension, hyperlipidemia, and non–insulin-dependent diabetes mellitus. The first step is to establish that the patient is hemodynamically stable and whether he needs inpatient evaluation Table 1. Study (n) Rate Control Versus Rhythm Control Studies Groups (n) Primary End Point Results 2 Rate: diltiazem⫹additional therapy if needed (125) Symptomatic improvement 76 patients (rate) vs 70 patients (rhythm); (palpitations, dyspnea, dizziness) P⫽0.317 Rhythm: pharmacological (amiodarone) and, if necessary, DC cardioversion⫹antiarrhythmic therapy (127) AFFIRM3 (4060) Rate: -blockers, calcium-channel blockers (verapamil All-cause mortality 25.9 % (rate) vs 26.7% (rhythm); 95% and diltiazem), digoxin, or combination (2027) confidence interval, 0.99 to 1.34; P⫽0.08 Rhythm: cardioversion as necessary⫹ antiarrhythmic drug chosen by physician (2033) Rate: digitalis, nondihydropyridine calcium-channel RACE4 (522) Composite cardiovascular death, 17.2% (rate) vs 22.6% (rhythm); 95% blocker, and/or -blocker (256) hospitalization for heart confidence interval, 0.53 to 1.01; failure, thromboembolic complications, P⫽0.11 Rhythm: DC cardioversion⫹sotalol, then severe hemorrhage, pacemaker flecainide or propafenone if needed, then implantation, severe adverse events amiodarone if needed (266) 5 Rate: -blockers, digitalis, calcium antagonists, or STAF (200) Composite death, stroke/transient 10 (rate) vs 9 events (rhythm); atrioventricular node ablation/modification (100) ischemic event, systemic embolism, P⫽0.99 cardiopulmonary resuscitation Rhythm: DC cardioversion⫹class I antiarrhythmic agents or sotalol, or if heart disease or impaired LV function, -blocker and/or amiodarone (100) Rate: -blockers, nondihydropyridine calcium HOT CAFE6 (205) Composite death, thromboembolic Odds ratio,1.98; 95% confidence blockers, digoxin, or combination (101) complications, and intracranial interval, 0.28 to 22.3; P⫽0.71 or other major hemorrhage Rhythm: DC cardioversion⫹antiarrhythmic therapy as indicated (104) Rate: -blockers, digoxin, or pacemaker and AV AF CHF7 (1376) Composite of cardiovascular death, 45.8% (rate) vs 42.7% (rhythm), node ablation if necessary (694) stroke, or worsening of heart failure P⫽0.20 Rhythm: DC cardioversion amiodarone, then sotalol and dofetilide if needed (682) PIAF (252) PIAF indicates Pharmacological Intervention in Atrial Fibrillation; DC, direct current; AFFIRM, Atrial Fibrillation Follow-up Investigation of Rhythm Management; RACE, Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group; STAF, Strategies of Treatment of Atrial Fibrillation; HOT CAFE, How to Treat Chronic Atrial Fibrillation; AF CHF, atrial fibrillation and congestive heart failure; and AV, atrioventricular. From the Lankenau Institute for Medical Research, Wynnewood, PA (M.D.E., T.H.A., T.S.) and Louisiana State University School of Medicine, New Orleans, LA (R.N.). Correspondence to Michael D. Ezekowitz, MBChB, DPhil, FRCP, Lankenau Institute for Medical Research, 100 Lancaster Ave, Suite G36, Wynnewood, PA 19096. E-mail [email protected] (Circulation. 2011;124:95-99.) © 2011 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.110.967455 95 96 Circulation July 5, 2011 Management goals are to rule out reversible causes of atrial fibrillation, maintain the heart rate at rest and with exercise in the physiological range, consider conversion to sinus rhythm, and determine which stroke prevention measures are needed. Reversible Causes of Atrial Fibrillation Downloaded from http://circ.ahajournals.org/ by guest on September 29, 2016 Reversible causes of atrial fibrillation are conveniently separated into cardiac and noncardiac causes. Noncardiac causes (electrolyte imbalance, thyrotoxicosis, fever from any cause [particularly pneumonia], pharmacological and recreational drug use, and alcohol use) were ruled out by history and physical and simple blood tests (thyroid function tests, serum electrolytes, and urine and serum toxicology). The cardiac causes of atrial fibrillation include any mechanism resulting in structural and functional changes to the heart. Transthoracic echocardiogram revealed moderate left ventricular hypertrophy but normal left ventricular systolic function, no evidence of valvular disease, normal left atrium and no pericardial effusion. An acute ischemic event was unlikely in view of the nonischemic ECG, no regional wall motion abnormalities by echocardiogram, and the absence of symptoms of ischemia. Rate Control Rate control, both at rest and with exercise, is central to the management of patients with atrial fibrillation. In this case, the patient was receiving a -blocker for his coronary disease and hypertension. His heart rate at presentation was acceptable. There is currently debate as to whether strict rate control at rest and with exercise is preferred over a more lenient approach. A recent report suggests that a lenient approach is acceptable.1 Drug options for maintaining a patient’s heart rate within the physiological range include -blockers, calcium-channel blockers such as diltiazem and verapamil, and digoxin. -Blockers are especially useful in the presence of associated coronary artery disease or myocardial ischemia with atrial fibrillation. Calcium-channel blockers are effective in short-term and long-term rate control, but should be avoided in patients with systolic heart failure because of negative inotropic effects. Digoxin may be useful in combination with -blockers in patients with heart failure. In this case, -blocker was recommended, given concomitant coronary artery disease and hypertension. Cardioversion The randomized trials that have compared rate control with cardioversion have shown no mortality benefit to either management strategy (Table 1).2–7 However, remodeling of the left atrium, both mechanically and electrically, may be minimized by early cardioversion to sinus rhythm.8 Other indications for cardioversion are patient symptoms. Usually, long-term success with cardioversion requires the concomitant use of an antiarrhythmic drug.9 For patients with symptomatic recurrent atrial fibrillation who failed 1 antiarrhythmic drug trial, curative catheter ablation should be considered. The most common approach currently used is exclusion of triggers by isolating pulmonary veins from the left atrium with linear or circumferential ablation. In this case, the patient was hemodynamically stable, and the deci- Table 2. Atrial Fibrillation Stroke Risk Stratification Schemes Schema and Components Points AF Investigators10 Age ⱖ65 y n/a History of Hypertension n/a Previous stroke/transient ischemic attack n/a Diabetes mellitus n/a CHADS211 Congestive heart failure 1 Hypertension 1 Age ⱖ75 y 1 Diabetes mellitus 1 Stroke/transient ischemic attack 2 Framingham Age 0–10 Female gender 6 Systolic blood pressure 0–4 Diabetes mellitus 5 Prior ischemic stroke/transient ischemic attack 6 7th ACCP CHA2DS2VASc12 Congestive heart failure/LV dysfunction 1 Hypertension 1 Age ⱖ75 y 2 Diabetes mellitus 1 Stroke/transient ischemic attack 2 Vascular disease (prior myocardial infarction, peripheral arterial disease, or aortic plaque 1 Age 65 to 74 y 1 Female gender 1 AF indicates Atrial Fibrillation; n/a, not applicable; and LV, left ventricular. sion to electrically cardiovert the patient was deferred (in case of spontaneous cardioversion) but not excluded. The current recommendation is therapeutic anticoagulation for at least 3 weeks before and at least 4 weeks after cardioversion. The cardioversion subanalysis of the RE-LY study demonstrated dabigatran to be a reasonable alternative to warfarin for stroke prevention in patients requiring cardioversion.10 Stroke Prevention The major complication of atrial fibrillation is stroke. The central pharmacological approach to stroke prevention in atrial fibrillation is anticoagulation. The decision to anticoagulate involves balancing stroke prevention and bleeding risk. Risk stratification algorithms have been developed (Table 2). The first one was developed in 1995 by the Atrial Fibrillation Investigators.11 These led to a quantified risk stratification system currently in use, which carries the acronym CHADS2 (congestive heart failure, hypertension, age ⱖ75 years, and diabetes mellitus are each assigned 1 point; previous stroke or transient ischemic attack is Ezekowitz et al Table 3. AF Management 97 Novel Oral Anticoagulants Pharmacological Agent Type Dosing Bioavailability, absolute or relative, % Dabigatran Tecafarin Rivaroxaban Apixaban Edoxaban Direct thrombin inhibitor Vitamin K antagonist Factor Xa inhibitor Factor Xa inhibitor Factor Xa inhibitor Fixed, twice daily Once daily Fixed, once daily Fixed, twice daily Fixed, once daily Absolute, 6.5 NA Relative, 60 to 80 Absolute, 60 to 66 Absolute, 50 Downloaded from http://circ.ahajournals.org/ by guest on September 29, 2016 Half-life, h 14–17 107–140 5–13 8–15 9–11 Excretion 80% Renal 100% esterases and hepatobiliary Dual mechanism, 66% renal 25% Renal Dual mechanism, 35% renal Drug interactions P-glycoprotein Low potential compared to warfarin CYP3A4 and P-glycoprotein CYP3A4 CYP3A4 and P-glycoprotein Phase III results RELY study17 completed. D 150 superior (1.1%; P⬍0.001) and D 110 noninferior (1.5%; P⫽0.34) to warfarin (1.7%) for stroke prevention.* Phase 2/3 study completed19 Greater time in therapeutic range with tecafarin vs warfarin (71% vs 59%) ROCKET-AF study20 completed Rivaroxaban 20 mg and 15 mg daily (renal patients) noninferior (1.7%; P⬍0.001) vs warfarin (2.1%) for prevention of stroke and systemic thromboembolism ARISTOTLE study21 comparing apixaban 5 mg BID vs warfarin (INR 2–3) ongoing. AVERROES study22,23 completed: In warfarin-ineligible patients, apixaban superior to ASA (1.6% vs 3.6%; RRR of 50%; P⬍0.001) for prevention of stroke and systemic thromboembolism 20 500 patient ENGAGE-AF TIMI 48 study24 is ongoing: Compares 2 doses, Edoxaban 30 mg daily and 60 mg daily with warfarin (INR 2–3) RELY indicates Randomized Evaluation of Long-term anticoagulation therapY; ROCKET-AF, Rivaroxaban: Once daily, oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation; ARISTOTLE, Apixaban for Reduction In STroke and Other ThromboemboLic Events in atrial fibrillation; INR, international normalized ratio; AVERROES, Apixaban versus Acetylsalicylic Acid to Prevent Strokes in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment; ASA, acetylsalicylic acid; RRR, relative risk reduction; and ENGAGE-AF TIMI, Effective aNticoaGulation with factor xA Next GEneration in Atrial Fibrillation. *The US Food and Drug Administration approved 150 mg BID at a creatine clearance of ⬎30 mL/min and 75 mg BID at a creatine clearance of ⬍30 mL/min. assigned 2).12 In patients with a CHADS2 score ⱖ2, long-term oral anticoagulation is recommended, unless contraindicated, with a goal international normalized ratio of 2 to 3. However, patients with CHADS2 score of 1(moderate risk) still derive benefit from long-term oral anticoagulation over aspirin, often with lower rate of major bleeding. Therefore, more recently, the Europeans have developed an expanded new risk stratification score for the elderly, the CHA2DS2 vascular score, that gives a point for age over 65 years, for being female, and for the presence of vascular disease (peripheral arterial disease, aortic plaque, or myocardial infarction) and 2 points for age ⬎75 years.13 This score is cumulative and a score of ⱖ2 requires long-term oral anticoagulation. These European guidelines recognize the stroke risk as a continuum and deemphasize the use of low-, moderate-, and high-risk categorization. The role of warfarin as the anticoagulant of choice is being challenged. The most exciting advances are the direct thrombin inhibitors. Ximelagatran achieved noninferiority with warfarin for stroke prevention, but was toxic to the liver and not approved.14,15 In the Randomized Evaluation of Longterm anticoagulation therapY (RELY) trial,16 the direct thrombin inhibitor dabigatran at 150 mg BID proved superior to warfarin for stroke prevention in patients with atrial fibrillation at risk of stroke.17 These results were achieved with a trend toward a reduced rate of major bleeding compared with warfarin. Dabigatran reduced intracranial hemorrhages by 60% in the 150 mg BID dose group compared with warfarin. Gastrointestinal symptoms leading to drug discontinuation occurred in 2.1% of patients in the 150 mg BID group compared with 0.6% in the warfarin group. Myocardial infarction rates were low, but slightly higher in the dabigatran group than in the warfarin group. Major gastrointestinal hemorrhages were higher in dabigatran group versus warfarin, 1.5% versus 1.1%. Dabigatran administration causes full anticoagulation within several hours of ingestion. Dabigatran is effective for stroke prevention in patients with atrial fibrillation regardless of prior warfarin exposure.18 The US Food and Drug Administration recently approved dabigatran for clinical use at the 150 mg BID dose for patients whose creatinine clearance exceeded 30 mL/min and 75 mg BID for patients between 15 and 30 mL/min. Several novel oral anticoagulants have completed or are in phase 3 trials (Table 3).19 –24 In our case, the patient had a history of hypertension and diabetes mellitus, which gave him a CHADS2 score of 2 and a CHAD2S2-VASC score of 4, with addition of 1 point for age ⬎65 years and 1 point for coronary artery disease. The patient had no contraindication to anticoagulation and had a creatinine clearance of 70 mL/min. Dabigatran was initiated at a dose of 150 mg BID. The patient remained in atrial fibrillation at a rate of about 70 bpm. For rhythm control, dronedarone, amiodarone, or dofetilide are considerations (Table 4). Flecainide and propafenone are contraindicated because of his history of coronary artery disease and potential for arrhythmia. Sotalol would need to be initiated on an in-patient basis, leaving amiodarone and dronedarone as the 2 remaining options. Dronedarone is a newly approved hepatically metabolized antiarrhythmic agent with a mechanism of action similar to amiodarone, but a 98 Table 4. Circulation July 5, 2011 Antiarrhythmic Options Vaughn Williams Class Downloaded from http://circ.ahajournals.org/ by guest on September 29, 2016 Examples Mechanism Indication Potential Side Effects IA Procainamide disopyramide Sodium-channel blocker. Decreases conduction velocity and prolongs action potential duration. Conversion of atrial flutter/fibrillation and maintenance of sinus rhythm. Procainamide metabolite (NAPA) can cause prolonged QT and lupus-like syndrome and is renally excreted. (tubular secretion). Its excretion is inhibited by cimetidine, trimethoprim etc. Anticholinergic effects are common with disopyramide. IC Flecainide, propafenone Sodium-channel blocker. Marked prolongation of conduction velocity. Used for atrial flutter/fibrillation in the absence of structural heart disease. Propafenone and Flecainide are excreted by the liver (CYP450) and has potential interaction with several drugs (warfarin, digoxin, etc). Flecainide caused increased mortality after MI (CAST trial). II -Blockers (eg, propranolol, metoprolol, atenolol)  Blockade (myocardial -1 receptor) and by blocking the action of catecholamines. Used for rate control in atrial arrhythmias (atrial flutter/fibrillation). Also useful to suppress ventricular ectopy of ischemic etiology. Generally well tolerated. Dose related slowing of heart rate. Can cause fatigue, depression and impotence. III Amiodarone, dofetilide, dronedarone, sotalol Prolongs action potential duration and increases the effective refractory period. Amiodarone and dronedarone blocks multiple cardiac ion channels and has properties of all Vaughn Williams drug classes. Atrial fibrillation. All except ibutilide are used for maintenance of sinus rhythm. Ibutilide is used for conversion of atrial fibrillation. Sotalol is useful in the presence of coronary artery disease. Amiodarone needs close monitoring for organ toxicity including thyroid, pulmonary, hepatic and ocular testing. Amiodarone is a potent inhibitor of several hepatic P 450 enzymes and has several drug-drug interactions. Dofetilide, Sotalol and Ibutilide can cause QT prolongation. Sotalol and Dofetilide are excreted by kidneys. Dronedarone is contraindicated in decompensated heart failure. IV Nondihydropyridine calcium-channel antagonists (verapamil and diltiazem) Interferes with calcium flux during plateau phase of action potential. Initial drugs of choice for paroxysmal supraventricular tachycardias such as AV nodal reentrant tachycardia. Also used for rate control in atrial arrhythmias (atrial flutter/fibrillation). Negative inotropy can worsen heart failure in patients with severe left ventricular dysfunction. Negative dromotropy can cause bradycardia and high grade AV block. Increase dabigatran serum levels. V Digoxin Digoxin effects phase 4 activity of action potential (potassium dependent). It decreases conduction velocity and increases effective refractory period. Used for rate control in atrial arrhythmias (atrial flutter/fibrillation). Narrow therapeutic window. Drug interactions are common (amiodarone, verapamil, dronedarone increase digoxin levels). Hypokalemia exacerbates digoxin toxicity. Potential for high grade AV block and fatal ventricular arrhythmias. AV indicates atrioventricular; MI, myocardial infarction. shorter half-life (⬇24 hours) and reduced tissue accumulation.25 History of severe heart failure is a contraindication. Dronedarone was initiated. Dronedarone increases dabigatran levels by 1.7 to 2-fold. His dose of aspirin was reduced to 81 mg, and clopidogrel was continued because of the drug-eluting stent. If the patient had a bare metal stent placed, it would be reasonable to stop clopidogrel at the time of warfarin or dabigatran initiation, because there is an increased risk of bleeding with dual antiplatelet therapy.26 –31 Ten days later, the patient remained asymptomatic. There was more bruising noted, but no bleeding. An electric cardioversion was planned for 3 weeks. Dronedarone was continued. Three weeks later, the patient remained in atrial fibrillation. He was successfully cardioverted without transesophageal echocardiography.10 Dabigatran was continued during the procedure and for an indefinite period after cardioversion. There were no complications. A month later, he remained in sinus rhythm. The patient will remain on droneadarone. Acknowledgments We gratefully acknowledge Dr Aaron Liu for help in editing the manuscript. Disclosures Dr Ezekowitz reports receiving consulting fees, lecture fees, and grant support from ARYx Therapeutics, Boehringer Ingelheim, Daiichi Sankyo, and Portola, and consulting fees from AstraZeneca, Bristol-Myers Squibb, Medtronic, Pfizer, and Sanofi-aventis. Dr Nagarakanti received lecture fees from Boehringer Ingelheim Pharmaceuticals. Please change accordingly. The other authors report no conflicts. References 1. Van Gelder IC, Groenveld HF, Crijns HJ, Tuininga YS, Tijssen JG, Alings AM, Hillege HL, Bergsma-Kadijk JA, Cornel JH, Kamp O, Tukkie R, Bosker HA, Van Veldhuisen DJ, Van den Berg MP, for the RACE II Investigators. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010;362:1363–1373. 2. Hohnloser SH, Kuck KH, Lilienthal J for the PIAF Investigators. Rhythm or rate control in atrial fibrillation: Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial. Lancet. 2000;356:1789 –1794. 3. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347:1825–1833. 4. Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJ, Tijssen JG, Crijns HJ for the Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group. A comparison of rate control and rhythm control in Ezekowitz et al 5. 6. 7. 8. 9. Downloaded from http://circ.ahajournals.org/ by guest on September 29, 2016 10. 11. 12. 13. 14. 15. 16. 17. 18. patients with recurrent persistent atrial fibrillation. N Engl J Med. 2002; 347:1834 –1840. Carlsson J, Miketic S, Windeler J, Cuneo A, Haun S, Micus S, Walter S, Tebbe U for the STAF Investigators. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. J Am Coll Cardiol. 2003;41:1690–1696. Opolski G, Torbicki A, Kosior DA, Szulc M, Wozakowska-Kaplon B, Kolodziej P, Achremczyk P, for the Investigators of the Polish HOT CAFE Trial. Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) study. Chest. 2004;126:476–486. Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, Bourassa MG, Arnold JM, Buxton AE, Camm AJ, Connolly SJ, Dubuc M, Ducharme A, Guerra PG, Hohnloser SH, Lambert J, Le Heuzey JY, O’Hara G, Pedersen OD, Rouleau JL, Singh BN, Stevenson LW, Stevenson WG, Thibault B, Waldo AL; Atrial Fibrillation and Congestive Heart Failure Investigators. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358:2667–2677. Wijffels MCEF, Kirchhof CJHJ, Dorland R, Alessie MA. Atrial fibrillation begets atrial fibrillation. Circulation. 1995;92:1954–1968. Singh BN, Singh SN, Reda DJ, Tang XC, Lopez B, Harris CL, Fletcher RD, Sharma SC, Atwood JE, Jacobson AK, Lewis HD Jr, Raisch DW, Ezekowitz MD, for the Sotalol Amiodarone Atrial Fibrillation Efficacy Trial (SAFE-T) Investigators. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med. 2005;352:1861–1872. Nagarakanti R, Ezekowitz MD, Oldgren J, Yang S, Chernick M, Aikens TH, Flaker G, Brugada J, Kamensky G, Parekh A, Reilly PA, Yusuf S, Connolly SJ. Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing cardioversion. Circulation. 2011;123:131–136. Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation: analysis of pooled data from 5 randomized controlled trials. Arch Intern Med. 1994;154:1449–1457. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001; 285:2864 –2870. The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Guidelines for the management of atrial fibrillation. Eur Heart J. 2010;31:2369 –2429. Albers GW, Diener HC, Grind M, Halperin JL, Horrow J, Olsson SB, Petersen P, Vahanian A, Frison L, Nevinson M, Partridge S; Executive Steering Committee on Behalf of the SPORTIF III Investigators. Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III): randomised controlled trial. Lancet. 2003;362:1691–1698. Albers GW, Diener HC, Frison L, Grind M, Nevinson M, Partridge S, Halperin JL, Horrow J, Olsson SB, Petersen P, Vahanian A; SPORTIF Executive Steering Committee for the SPORTIF V Investigators. Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation. JAMA. 2005;293:690 – 698. Ezekowitz MD, Connolly S, Parekh A, Reilly PA, Varrone J, Wang S, Oldgren J, Themeles E, Wallentin L, Yusuf S. Rationale and design of RE-LY: randomized evaluation of long-term anticoagulant therapy, warfarin, compared with dabigatran. Am Heart J. 2009;157:805– 810,810. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener H-C, Joyner CD, Wallentin L; the RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361: 1139 –1151. Ezekowitz MD, Wallentin L, Connolly SJ, Parekh A, Chernick MR, Pogue J, Aikens TH, Yang S, Reilly PA, Lip GY, Yusuf S, RE-LY Steering Committee and Investigators. Dabigatran and warfarin in 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. AF Management 99 vitamin K antagonist-naive and -experienced cohorts with atrial fibrillation. Circulation. 2010;122:2246 –2253. Ellis DJ, Usman MH, Milner PG, Canafax DM, Ezekowitz MD. The first evaluation of a novel vitamin K antagonist, tecarfarin (ATI-5923), in patients with atrial fibrillation. Circulation. 2009;120:1029 –1035. The Executive Steering Committee, on behalf of the ROCKET AF Study Investigators. Rivaroxaban: Once daily, oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation: rationale and design of the ROCKET AF study. Am Heart J. 2010;159:340.e1–347.e1. Lopes RD, Alexander JH, Al-Khatib SM, Ansell J, Diaz R, Easton JD, Gersh BJ, Granger CB, Hanna M, Horowitz J, Hylek EM, McMurray JJ, Verheugt FW, Wallentin L; ARISTOTLE Investigators. Apixaban for Reduction In STroke and Other ThromboemboLic Events in atrial fibrillation (ARISTOTLE) trial: design and rationale. Am Heart J. 2010;159: 331–339. Eikelboom JW, O’Donnell M, Yusuf S, Diaz R, Flaker G, Hart R, Hohnloser S, Joyner C, Lawrence J, Pais P, Pogue J, Synhorst D, Connolly SJ. Rationale and design of AVERROES: Apixaban versus acetylsalicylic acid to prevent stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment. Am Heart J. 2010;159:348.e1–353.e1. Connolly SJ , Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S, Flaker G, Avezum A, Hohnloser SH, Diaz R, Talajic M, Zhu J, Pais P, Budaj A, Parkhomenko A, Jansky P, Commerford P, Tan RS, Sim KH, Lewis BS, Van Mieghem W, Lip GY, Kim JH, Lanas-Zanetti F, Gonzalez-Hermosillo A, Dans AL, Munawar M, O’Donnell M, Lawrence J, Lewis G, Afzal R, Yusuf S; the AVERROES Steering Committee and Investigators. Apixaban in patients with atrial fibrillation. N Engl J Med. 2011;364:806–817. Ruff CT, Giugliano RP, Antman EM, Crugnale SE, Bocanegra T, Mercuri M, Hanyok J, Patel I, Shi M, Salazar D, McCabe CH, Braunwald E. Evaluation of the novel factor Xa inhibitor edoxaban compared with warfarin in patients with atrial fibrillation: design and rationale for the Effective aNticoaGulation with factor xA next GEneration in Atrial Fibrillation-Thrombolysis In Myocardial Infarction study 48 (ENGAGE AF-TIMI 48). Am Heart J. 2010;160:635–641. Hohnloser SH, Crijns HJ, van Eickels M, Gaudin C, Page RL, Torp-Pedersen C, Connolly SJ; ATHENA Investigators. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med. 2009;360:668–678. Hansen ML, Sørensen R, Clausen MT, Fog-Petersen ML, Raunsø J, Gadsbøll N, Gislason GH, Folke F, Andersen SS, Schramm TK, Abildstrøm SZ, Poulsen HE, Køber L, Torp-Pedersen C. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med. 2010;170:1433–1441. Ruiz-Nodar JM, Marı́n F, Hurtado JA, Valencia J, Pinar E, Pineda J, Gimeno JR, Sogorb F, Valdés M, Lip GY. Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation implications for bleeding risk and prognosis. J Am Coll Cardiol. 2008;51:818–825. Manzano-Fernández S, Pastor FJ, Marı́n F, Cambronero F, Caro C, Pascual-Figal DA, Garrido IP, Pinar E, Valdés M, Lip GY. Increased major bleeding complications related to triple antithrombotic therapy usage in patients with atrial fibrillation undergoing percutaneous coronary artery stenting. Chest. 2008;134:559 –567. Karjalainen PP, Porela P, Ylitalo A, Vikman S, Nyman K, Vaittinen MA, Airaksinen TJ, Niemelä M, Vahlberg T, Airaksinen KE. Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting. Eur Heart J. 2007;28:726 –732. DeEugenio D, Kolman L, DeCaro M, Andrel J, Chervoneva I, Duong P, Lam L, McGowan C, Lee G, DeCaro M, Ruggiero N, Singhal S, Greenspon A. Risk of major bleeding with concomitant dual antiplatelet therapy after percutaneous coronary intervention in patients receiving long-term warfarin therapy. Pharmacotherapy. 2007;27:691–696. Khurram Z, Chou E, Minutello R, Bergman G, Parikh M, Naidu S, Wong SC, Hong MK. Combination therapy with aspirin, clopidogrel and warfarin following coronary stenting is associated with a significant risk of bleeding. J Invasive Cardiol. 2006;18:162–164. Atrial Fibrillation: Outpatient Presentation and Management Michael D. Ezekowitz, Timothy H. Aikens, Rangadham Nagarakanti and Timothy Shapiro Downloaded from http://circ.ahajournals.org/ by guest on September 29, 2016 Circulation. 2011;124:95-99 doi: 10.1161/CIRCULATIONAHA.110.967455 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2011 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/124/1/95 Data Supplement (unedited) at: http://circ.ahajournals.org/content/suppl/2016/04/13/124.1.95.DC1.html Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/ Page 87 Mise au point clinique La fibrillation auriculaire Tableau clinique et prise en charge des patients ambulatoires Michael D. Ezekowitz, MBChB, DPhil, FRCP ; Timothy H. Aikens, BA ; Rangadham Nagarakanti, MD ; Timothy Shapiro, MD as clinique—Un homme blanc de 68 ans se présente en consultation de cardiologie pour une légère asthénie. Le premier élément relevé est une irrégularité du pouls nouvellement apparue. La présence d’une fibrillation auriculaire est confirmée par l’ECG à douze dérivations. Le patient ne présente aucun autre symptôme. Quatre mois plus tôt, un stent à libération de médicament lui avait été posé pour traiter une petite lésion de la portion proximale de l’artère interventriculaire antérieure. Les antécédents médicaux comprennent une hypertension artérielle, une hyperlipidémie et un diabète non insulinodépendant. La première étape consiste à déterminer si le patient est en situation hémodynamique stable et s’il y a lieu de l’hospitaliser pour rechercher une éventuelle pathologie associée. Sa pression artérielle est normale (125/80 mmHg) et il présente un rythme cardiaque irrégulier (72 battements/min) mais bien contrôlé par la prise quotidienne de 50 mg d’aténolol. Il n’existe aucune anomalie électrocardiographique en dehors de la fibrillation auriculaire, ce qui est en faveur d’un processus aigu. L’auscultation objective un court souffle systolique d’intensité 1/6 à l’apex, sans irradiation. Il n’existe aucun signe d’insuffisance cardiaque. L’examen neurologique est normal. Le patient prend quotidiennement 50 mg d’aténolol, 5 mg de lisinopril, de la metformine, 20 mg d’atorvastatine, 325 mg d’aspirine et 75 mg de clopidogrel. L’hospitalisation ne s’impose pas dans l’immédiat. La prise en charge va viser à éliminer une éventuelle cause réversible de fibrillation auriculaire, à maintenir la fréquence cardiaque de repos et d’effort dans les limites physiologiques, à envisager la restauration du rythme sinusal et à définir les mesures à mettre en œuvre pour prévenir la survenue d’un accident vasculaire cérébral (AVC). de l’examen physique et de ceux du bilan sanguin standard (tests fonctionnels thyroïdiens, ionogramme sanguin et dosages toxicologiques sériques et urinaires). Les causes cardiaques de fibrillation auriculaire sont représentées par tout processus modifiant les caractéristiques structurales et/ou fonctionnelles du cœur. L’échocardiographie transthoracique pratiquée chez le patient révèle une hypertrophie ventriculaire gauche modérée avec toutefois une fonction systolique ventriculaire gauche normale, une absence de valvulopathie cardiaque, une oreillette gauche normale et une absence d’épanchement péricardique. L’éventualité d’un événement ischémique aigu apparaît improbable compte tenu de l’absence de signe électrocardiographique d’ischémie, de trouble segmentaire de la mobilité pariétale à l’échocardiographie et de symptômes ischémiques. C Régularisation de la fréquence cardiaque Le rétablissement d’un rythme cardiaque normal, au repos comme à l’effort, est l’élément clé de la prise en charge des patients atteints de fibrillation auriculaire. Dans le cas qui nous occupe, le patient recevait un bêtabloquant pour traiter sa maladie coronaire et son hypertension artérielle. Sa fréquence cardiaque à l’admission était acceptable. Actuellement, les avis sont partagés quant à la question de savoir s’il y a lieu de privilégier la régularisation stricte de la fréquence cardiaque de repos et d’effort par rapport à une attitude plus souple. Selon une récente étude, cette dernière approche serait acceptable.1 Les médicaments pouvant être utilisés en vue de maintenir la fréquence cardiaque d’un patient dans les limites physiologiques comprennent les bêtabloquants, les inhibiteurs calciques tels que le diltiazem et le vérapamil ainsi que la digoxine. Les bêtabloquants sont particulièrement utiles lorsque la fibrillation auriculaire est associée à une maladie coronaire ou à une ischémie myocardique. Les inhibiteurs calciques sont efficaces pour régulariser le rythme cardiaque à court et long termes, mais doivent être évités chez les patients atteints d’insuffisance cardiaque systolique en raison de leur effet inotrope négatif. La digoxine peut être intéressante en association avec un bêtabloquant chez les patients insuffisants cardiaques. Dans le cas présent, un bêtabloquant est recommandé compte tenu de la coexistence d’une maladie coronaire et d’une hypertension artérielle. Causes réversibles de fibrillation auriculaire Pour la commodité, les causes réversibles de fibrillation auriculaire sont séparées en causes cardiaques et extracardiaques. Chez ce patient, ces dernières (déséquilibre électrolytique, hyperthyroïdie, fièvre liée à une quelconque origine [notamment une pneumopathie], prise de médicaments ou de drogues à usage récréatif et consommation d’alcool) sont écartées au vu des antécédents, des résultats Institut Lankenau de Recherche Médicale, Wynnewood, Pennsylvanie, Etats-Unis (M.D.E., T.H.A., T.S.) ; et Faculté de Médecine de l’Université d’Etat de la Louisiane, Nouvelle-Orléans, Louisiane, Etats-Unis (R.N.). Correspondance : Michael D. Ezekowitz, MBChB, DPhil, FRCP, Lankenau Institute for Medical Research, 100 Lancaster Ave, Suite G36, Wynnewood, PA 19096. E-mail: [email protected] (Traduit de l’anglais : Atrial Fibrillation. Outpatient Presentation and Management. Circulation. 2011;124:95–99.) © 2012 American Heart Association, Inc. Circulation est disponible sur http://circ.ahajournals.org 87 08:38:12:04:12 Page 87 Page 88 88 Circulation Tableau 1. Mars 2012 Etudes ayant comparé le ralentissement de la fréquence cardiaque versus la restauration du rythme sinusal Cardioversion Les essais randomisés menés pour comparer le ralentissement de la fréquence cardiaque à la cardioversion n’ont objectivé aucune supériorité de l’une ou l’autre de ces stratégies de prise en charge en termes d’amélioration de la mortalité (Tableau 1).2–7 Il semble néanmoins que le rétablissement précoce du rythme sinusal contribue à réduire fortement le remodelage de l’oreillette gauche, tant mécanique qu’électrique.8 Les autres indications de la cardioversion sont déterminées par la présence de symptômes chez le patient. Habituellement, le maintien à long terme du succès de la cardioversion réclame la prescription concomitante d’un antiarythmique.9 Lorsqu’un patient présente une récidive de fibrillation auriculaire symptomatique que l’on a tenté sans succès de réduire par l’administration d’un antiarythmique, il y a lieu d’envisager un traitement ablatif par cathéter. La technique la plus fréquemment employée à l’heure actuelle consiste à supprimer les zones gâchettes en isolant les veines pulmonaires de l’oreillette gauche par la réalisation de lésions linéaires ou circulaires. Dans le cas qui nous occupe, le patient présente un état hémodynamique stable, de sorte que la mise en œuvre d’une cardioversion par choc électrique externe est différée (dans l’éventualité où le rythme sinusal se rétablirait spontanément) sans pour autant être définitivement exclue. La recommandation actuelle est d’instaurer une 08:38:12:04:12 Page 88 anticoagulation thérapeutique au moins 3 semaines avant la cardioversion et de la poursuivre pendant un minimum de 4 semaines une fois celle-ci pratiquée. La sous-analyse sur les cardioversions effectuée dans le cadre de l’étude RE-LY a montré qu’il est raisonnablement envisageable de remplacer la warfarine par le dabigatran pour prévenir le risque d’AVC chez les patients relevant d’une cardioversion.10 Prévention des accidents vasculaires cérébraux La principale complication de la fibrillation auriculaire est l’AVC. L’approche pharmacologique essentielle pour prévenir la survenue d’un tel événement est l’anticoagulation. La décision d’instaurer un traitement anticoagulant implique toutefois de mettre en balance la prévention de l’AVC et le risque hémorragique. Des algorithmes de stratification du risque sont disponibles à cette fin (Tableau 2). Le premier d’entre eux a été élaboré en 1995 par le groupe des Atrial Fibrillation Investigators.11 Ces derniers ont conçu un système de cotation du risque toujours utilisé, qu’ils ont désigné par l’acronyme CHADS2 (l’insuffisance cardiaque congestive [C], l’hypertension artérielle [H], l’âge égal ou supérieur à 75 ans [A] et le diabète [D] comptent chacun pour 1 point ; les antécédents d’AVC ou d’accident ischémique transitoire [AIT] comptent pour 2 points [S2]).12 Chez les patients dont le score CHADS2 est égal ou supérieur à 2, un traitement Page 89 Ezekowitz et al Tableau 2. Modèles de stratification du risque d’accident vasculaire cérébral lié à la présence d’une fibrillation auriculaire anticoagulant oral au long cours est recommandé s’il n’existe pas de contre-indication, en veillant à maintenir le rapport normalisé international entre 2 et 3. Cela étant, même lorsque le score CHADS2 est de 1 (traduisant un risque modéré), un traitement anticoagulant oral à long terme demeure préférable à l’administration d’aspirine, l’incidence des épisodes hémorragiques graves étant souvent plus faible. Plus récemment, les Européens ont élaboré un score de risque plus étoffé spécifiquement destiné au sujet âgé, le score vasculaire CHA2DS2, dans lequel l’âge supérieur à 65 ans, le sexe féminin et la présence d’une affection vasculaire (artériopathie périphérique, plaque aortique ou infarctus du myocarde) sont cotés 1 point chacun, alors que l’âge supérieur à 75 ans compte pour 2 points.13 Ce système de cotation est cumulatif, un score de 2 ou plus justifiant l’instauration d’un traitement anticoagulant oral à long terme. Ces recommandations 08:38:12:04:12 Page 89 Prise en charge de la FA 89 européennes avalisent la notion selon laquelle le risque d’AVC réalise un continuum, minimisant par là même l’importance jusqu’alors accordée à la classification en risques faible, modéré et élevé. La place privilégiée accordée à la warfarine dans le traitement anticoagulant est aujourd’hui remise en question. Les progrès les plus marquants ont été accomplis dans le domaine des inhibiteurs directs de la thrombine. Le ximélagatran a fait la preuve de sa non-infériorité par rapport à la warfarine dans la prévention des AVC, mais n’a pas reçu d’autorisation de mise sur le marché en raison de son hépatotoxicité.14,15 Dans l’essai RE-LY (Randomized Evaluation of Long-term anticoagulation therapY [évaluation randomisée du traitement anticoagulant au long cours]),16 l’administration de dabigatran, un autre inhibiteur direct de la thrombine, à la posologie de 150 mg deux fois par jour s’est avérée supérieure au traitement par la warfarine pour prévenir la survenue d’AVC chez les patients exposés à ce risque du fait de l’existence d’une fibrillation auriculaire.17 Il a également été noté une tendance à la diminution de l’incidence des hémorragies graves comparativement à celle relevée sous warfarine. Dans le groupe traité par deux prises journalières de 150 mg de dabigatran, le taux d’hémorragies intracrâniennes a été abaissé de 60 % comparativement à celui enregistré sous warfarine. Toutefois, l’incidence des symptômes digestifs ayant conduit à interrompre le traitement a été de 2,1 % dans le groupe traité par le dabigatran à raison de 150 mg deux fois par jour, contre seulement 0,6 % dans le groupe ayant reçu de la warfarine. Les taux d’infarctus du myocarde ont été faibles dans les deux groupes, mais l’incidence de cet événement a été légèrement plus élevée sous dabigatran que sous warfarine. Les hémorragies digestives graves ont été plus fréquentes dans le groupe traité par le dabigatran que dans celui ayant reçu de la warfarine (1,5 % contre 1,1 %). L’administration de dabigatran induit une anticoagulation complète dans les heures qui suivent la prise. Le médicament est efficace pour prévenir le risque d’AVC chez les patients en fibrillation auriculaire, que ces derniers aient été ou non précédemment exposés à la warfarine.18 La Food and Drug Administration des Etats-Unis a récemment autorisé l’utilisation clinique du dabigatran à la posologie de 150 mg deux fois par jour chez les patients dont la clairance de la créatinine excède 30 ml/min et à raison de 75 mg deux fois par jour chez ceux ayant une clairance de la créatinine comprise entre 15 et 30 ml/min. Plusieurs nouveaux anticoagulants oraux ont d’ores et déjà achevé leur cycle d’évaluation ou sont en cours d’expérimentation dans des essais de phase III (Tableau 3).19–24 Le patient dont il est ici question est hypertendu et diabétique, ce qui lui a fait attribuer un score CHADS2 de 2 et un score CHAD2S2 vasculaire de 4 puisque son âge supérieur à 65 ans et sa maladie coronaire comptent chacun pour un point supplémentaire. Le patient ne présente aucune contreindication à l’administration d’un traitement anticoagulant et sa clairance de la créatinine est de 70 ml/min. Il lui est donc prescrit du dabigatran à la posologie de 150 mg deux fois par jour. Le patient demeure en fibrillation auriculaire, avec une fréquence cardiaque d’environ 70 battements/min. Page 90 90 Circulation Tableau 3. Mars 2012 Nouveaux anticoagulants oraux Pour restaurer le rythme sinusal, il est envisageable d’utiliser la dronédarone, l’amiodarone, ou le dofétilide (Tableau 4). Le flécaïnide et la propafénone sont contre-indiqués chez ce patient en raison de ses antécédents coronariens et du potentiel arythmogène de ces médicaments. Le sotalol ne peut être instauré que dans le cadre d’une hospitalisation, de sorte que l’amiodarone et la dronédarone demeurent les deux seules options possibles. La dronédarone est un antiarythmique nouvellement apparu sur le marché, qui est métabolisé par le foie et répond au même mécanisme d’action que l’amiodarone, mais se distingue de celle-ci par sa demi-vie plus courte (de l’ordre de 24 heures) et par son accumulation tissulaire plus faible.25 Le médicament est contre-indiqué en cas de préexistence d’une insuffisance cardiaque sévère. Le patient est finalement placé sous dronédarone. Celle-ci a toutefois pour effet d’élever le taux sérique de dabigatran à un niveau 1,7 à 2 fois supérieur. La dose d’aspirine prescrite au patient est abaissée à 81 mg, le clopidogrel étant par ailleurs poursuivi en raison de la présence du stent à libération de médicament. Si le stent posé avait été en métal nu, il eût été raisonnable d’arrêter le clopidogrel à l’instauration de la warfarine ou du dabigatran, car la bithérapie antiagrégante plaquettaire augmente le risque hémorragique.26–31 08:38:12:04:12 Page 90 Dix jours plus tard, le patient est toujours asymptomatique. Il présente davantage d’hématomes, mais aucun épisode hémorragique n’a été constaté. Une cardioversion par choc électrique externe est programmée à trois semaines. La dronédarone est poursuivie. Trois semaines plus tard, le patient demeure en fibrillation auriculaire. La cardioversion est entreprise avec succès, sans pratiquer d’échocardiographie transœsophagienne.10 Le dabigatran est maintenu pendant l’intervention et poursuivi pendant une durée indéfinie après cette dernière. Aucune complication n’est enregistrée. Un mois plus tard, le patient est toujours en rythme sinusal. Il sera maintenu sous dronédarone. Remerciements Nous remercions chaleureusement le Dr Aaron Liu pour l’aide apportée à la rédaction du présent manuscrit. Déclarations Le Dr Ezekowitz a été rémunéré en qualité de consultant et de conférencier par ARYx Therapeutics, Boehringer Ingelheim, Daiichi Sankyo et Portola, ces sociétés ayant, en outre, subventionné ses travaux ; il a également été rémunéré en qualité de consultant par AstraZeneca, Bristol-Myers Squibb, Medtronic, Pfizer et SanofiAventis. Le Dr Nagarakanti a été rémunéré en qualité de conférencier par Boehringer Ingelheim Pharmaceuticals. Veuillez modifier comme il convient. Les autres auteurs n’ont aucun conflit d’intérêts à signaler. Page 91 Ezekowitz et al Tableau 4. 91 Options en matière d’antiarythmiques Références 1. Van Gelder IC, Groenveld HF, Crijns HJ, Tuininga YS, Tijssen JG, Alings AM, Hillege HL, Bergsma-Kadijk JA, Cornel JH, Kamp O, Tukkie R, Bosker HA, Van Veldhuisen DJ, Van den Berg MP, for the RACE II Investigators. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010;362:1363–1373. 2. Hohnloser SH, Kuck KH, Lilienthal J for the PIAF Investigators. Rhythm or rate control in atrial fibrillation: Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial. Lancet. 2000;356:1789–1794. 3. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD; Atrial Fibrillation Follow-up Investigation of Rhythm Management 08:38:12:04:12 Prise en charge de la FA Page 91 (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347: 1825–1833. 4. Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJ, Tijssen JG, Crijns HJ for the Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med. 2002;347:1834–1840. 5. Carlsson J, Miketic S, Windeler J, Cuneo A, Haun S, Micus S, Walter S, Tebbe U for the STAF Investigators. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. J Am Coll Cardiol. 2003;41:1690–1696. Page 92 92 Circulation Mars 2012 6. Opolski G, Torbicki A, Kosior DA, Szulc M, Wozakowska-Kaplon B, Kolodziej P, Achremczyk P, for the Investigators of the Polish HOT CAFE Trial. Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) study. Chest. 2004;126: 476–486. 7. Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, Bourassa MG, Arnold JM, Buxton AE, Camm AJ, Connolly SJ, Dubuc M, Ducharme A, Guerra PG, Hohnloser SH, Lambert J, Le Heuzey JY, O’Hara G, Pedersen OD, Rouleau JL, Singh BN, Stevenson LW, Stevenson WG, Thibault B, Waldo AL; Atrial Fibrillation and Congestive Heart Failure Investigators. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358: 2667–2677. 8. Wijffels MCEF, Kirchhof CJHJ, Dorland R, Alessie MA. Atrial fibrillation begets atrial fibrillation. Circulation. 1995;92:1954–1968. 9. Singh BN, Singh SN, Reda DJ, Tang XC, Lopez B, Harris CL, Fletcher RD, Sharma SC, Atwood JE, Jacobson AK, Lewis HD Jr, Raisch DW, Ezekowitz MD, for the Sotalol Amiodarone Atrial Fibrillation Efficacy Trial (SAFE-T) Investigators. Amiodarone versus sotalol for atrial fibrillation. N Engl J Med. 2005;352:1861–1872. 10. Nagarakanti R, Ezekowitz MD, Oldgren J, Yang S, Chernick M, Aikens TH, Flaker G, Brugada J, Kamensky G, Parekh A, Reilly PA, Yusuf S, Connolly SJ. Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing cardioversion. Circulation. 2011;123:131–136. 11. Atrial Fibrillation Investigators. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation: analysis of pooled data from 5 randomized controlled trials. Arch Intern Med. 1994;154:1449–1457. 12. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864–2870. 13. The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Guidelines for the management of atrial fibrillation. Eur Heart J. 2010;31:2369–2429. 14. Albers GW, Diener HC, Grind M, Halperin JL, Horrow J, Olsson SB, Petersen P, Vahanian A, Frison L, Nevinson M, Partridge S; Executive Steering Committee on Behalf of the SPORTIF III Investigators. Stroke prevention with the oral direct thrombin inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial fibrillation (SPORTIF III): randomised controlled trial. Lancet. 2003;362: 1691–1698. 15. Albers GW, Diener HC, Frison L, Grind M, Nevinson M, Partridge S, Halperin JL, Horrow J, Olsson SB, Petersen P, Vahanian A; SPORTIF Executive Steering Committee for the SPORTIF V Investigators. Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation. JAMA. 2005;293:690–698. 16. Ezekowitz MD, Connolly S, Parekh A, Reilly PA, Varrone J, Wang S, Oldgren J, Themeles E, Wallentin L, Yusuf S. Rationale and design of RE-LY: randomized evaluation of long-term anticoagulant therapy, warfarin, compared with dabigatran. Am Heart J. 2009;157:805–810. 17. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener H-C, Joyner CD, Wallentin L; the RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361:1139–1151. 18. Ezekowitz MD, Wallentin L, Connolly SJ, Parekh A, Chernick MR, Pogue J, Aikens TH, Yang S, Reilly PA, Lip GY, Yusuf S, RE-LY Steering Committee and Investigators. Dabigatran and warfarin in vitamin K antagonist-naive and -experienced cohorts with atrial fibrillation. Circulation. 2010;122:2246–2253. 19. Ellis DJ, Usman MH, Milner PG, Canafax DM, Ezekowitz MD. The first evaluation of a novel vitamin K antagonist, tecarfarin (ATI-5923), in patients with atrial fibrillation. Circulation. 2009;120:1029–1035. 08:38:12:04:12 Page 92 20. The Executive Steering Committee, on behalf of the ROCKET AF Study Investigators. Rivaroxaban: Once daily, oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation: rationale and design of the ROCKET AF study. Am Heart J. 2010;159:340.e1–347.e1. 21. Lopes RD, Alexander JH, Al-Khatib SM, Ansell J, Diaz R, Easton JD, Gersh BJ, Granger CB, Hanna M, Horowitz J, Hylek EM, McMurray JJ, Verheugt FW, Wallentin L; ARISTOTLE Investigators. Apixaban for Reduction In STroke and Other ThromboemboLic Events in atrial fibrillation (ARISTOTLE) trial: design and rationale. Am Heart J. 2010;159:331–339. 22. Eikelboom JW, O’Donnell M, Yusuf S, Diaz R, Flaker G, Hart R, Hohnloser S, Joyner C, Lawrence J, Pais P, Pogue J, Synhorst D, Connolly SJ. Rationale and design of AVERROES: Apixaban versus acetylsalicylic acid to prevent stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment. Am Heart J. 2010;159:348.e1–353.e1. 23. Connolly SJ , Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S, Flaker G, Avezum A, Hohnloser SH, Diaz R, Talajic M, Zhu J, Pais P, Budaj A, Parkhomenko A, Jansky P, Commerford P, Tan RS, Sim KH, Lewis BS, Van Mieghem W, Lip GY, Kim JH, Lanas-Zanetti F, Gonzalez-Hermosillo A, Dans AL, Munawar M, O’Donnell M, Lawrence J, Lewis G, Afzal R, Yusuf S; the AVERROES Steering Committee and Investigators. Apixaban in patients with atrial fibrillation. N Engl J Med. 2011;364:806–817. 24. Ruff CT, Giugliano RP, Antman EM, Crugnale SE, Bocanegra T, Mercuri M, Hanyok J, Patel I, Shi M, Salazar D, McCabe CH, Braunwald E. Evaluation of the novel factor Xa inhibitor edoxaban compared with warfarin in patients with atrial fibrillation: design and rationale for the Effective aNticoaGulation with factor xA next GEneration in Atrial Fibrillation-Thrombolysis In Myocardial Infarction study 48 (ENGAGE AF-TIMI 48). Am Heart J. 2010;160: 635–641. 25. Hohnloser SH, Crijns HJ, van Eickels M, Gaudin C, Page RL, Torp-Pedersen C, Connolly SJ; ATHENA Investigators. Effect of dronedarone on cardiovascular events in atrial fibrillation. N Engl J Med. 2009;360:668–678. 26. Hansen ML, Sørensen R, Clausen MT, Fog-Petersen ML, Raunsø J, Gadsbøll N, Gislason GH, Folke F, Andersen SS, Schramm TK, Abildstrøm SZ, Poulsen HE, Køber L, Torp-Pedersen C. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med. 2010;170:1433–1441. 27. Ruiz-Nodar JM, Marín F, Hurtado JA, Valencia J, Pinar E, Pineda J, Gimeno JR, Sogorb F, Valdés M, Lip GY. Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation implications for bleeding risk and prognosis. J Am Coll Cardiol. 2008;51:818–825. 28. Manzano-Fernández S, Pastor FJ, Marín F, Cambronero F, Caro C, Pascual-Figal DA, Garrido IP, Pinar E, Valdés M, Lip GY. Increased major bleeding complications related to triple antithrombotic therapy usage in patients with atrial fibrillation undergoing percutaneous coronary artery stenting. Chest. 2008;134:559–567. 29. Karjalainen PP, Porela P, Ylitalo A, Vikman S, Nyman K, Vaittinen MA, Airaksinen TJ, Niemelä M, Vahlberg T, Airaksinen KE. Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting. Eur Heart J. 2007;28:726–732. 30. DeEugenio D, Kolman L, DeCaro M, Andrel J, Chervoneva I, Duong P, Lam L, McGowan C, Lee G, DeCaro M, Ruggiero N, Singhal S, Greenspon A. Risk of major bleeding with concomitant dual antiplatelet therapy after percutaneous coronary intervention in patients receiving long-term warfarin therapy. Pharmacotherapy. 2007;27:691–696. 31. Khurram Z, Chou E, Minutello R, Bergman G, Parikh M, Naidu S, Wong SC, Hong MK. Combination therapy with aspirin, clopidogrel and warfarin following coronary stenting is associated with a significant risk of bleeding. J Invasive Cardiol. 2006;18:162–164.